Social Determinants Related to GI Nutrition
1.
The Social Determinants Related to GI Nutrition survey project was approved by the University of Michigan's Internal Review Board (IRB). The IRB number is HUM000198152. The anonymous survey (approximately 5 minutes) investigates how nutrition impacts GI disorders. By selecting Yes to this question, it will indicate informed consent to participate in this project. Selecting No, the survey will close.
Yes
No
2.
Have you been diagnosed with Irritable Bowel Syndrome?
Yes
No
3.
What is your primary Irritable Bowel Syndrome complaint?
Constipation
Diarrhea
Constipation and Diarrhea
4.
Gender
Male
Female
5.
What is your zip code?
6.
Ethnicity, what is your race?
Caucasian
African-American
Latino or Hispanic
Asian
Native American
Native Hawaiian or Pacific Islander
Middle Eastern
7.
How many family members, including yourself, do you currently live with?
8.
What is your housing situation today?
I have housing
I do not have housing (staying with others; in a hotel; living in a shelter; living outside on the street, on a beach, in a car, or in a park)
I choose not to answer
9.
Are you worried about losing your housing?
Yes
No
I choose not to answer this question
10.
What is the highest level of school that you have finished?
Less than high school disagree
High school diploma or GED
More than a high school diploma or GED
I choose not to answer this question
11.
What is your current work situation?
Unemployed
Part-Time or Temporary Work
Full-Time
Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)
I choose not to answer this question
12.
What is your main insurance?
None/Uninsured
CHIP Medicaid
Other Public Insurance (not CHIP)
Private Insurance
Medicaid
Medicare
13.
During the past year, what was the total combined income for you and the family members you live with?
$0.00 - $24,999
$25,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 - $199,999
Greater than $200,000
I choose not to answer this question
14.
In the past year, have you or any family member you live with been unable to get food when it was really needed?
Yes
No
15.
In the past year, have you or any family member you live with been unable to get utilities when it was really needed?
Yes
No
16.
In the past year, have you or any family member you live with been unable to get clothing when it was really needed?
Yes
No
17.
In the past year, have you or any family member you live with been unable to get childcare when it was really needed?
Yes
No
18.
In the past year, have you or any family member you live with been unable to get medicine or healthcare (medical, dental, mental health, vision) when it was needed?
Yes
No
19.
In the past year, have you or any family member been unable to get a phone when it was really needed?
Yes
No
20.
Has a lack of transportation kept you from medical appointments, meetings, work, or from getting things for daily living (check all that apply)?
Yes, it has kept me from medical appointments
Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
No
I choose not to answer this question
21.
Within the past 12 months, we worried whether our food would run out before we got money to buy more: this statement is
Often True
Sometimes True
Never True
22.
Within the past 12 months, the food we bought just didn't last and we didn't have money to get more. This statement is
Often True
Sometimes True
Never True
23.
Is it easy for you to get to a local grocery store?
Yes
No
24.
Do you have fresh fruits and vegetables to purchase near your home?
Yes
No
25.
Has a healthcare provider ever recommended a low FODMAP diet to help treat gastrointestinal symptoms? (symptoms including diarrhea, bloating, abdominal pain, constipation, nausea, vomiting, hear burn, fecal incontinence, etc)?
Yes
No
26.
Have you ever considered starting a low FODMAP diet to help treat gastrointestinal symptoms on your own? (symptoms including diarrhea, bloating, abdominal pain, constipation, nausea, vomiting, heart burn, fecal incontinence, etc.)
Yes
No
Not Applicable
27.
Have you visited with a registered dietician to learn about the low FODMAP diet?
Yes
No
Not Applicable
28.
What resources did you use to help guide you on a low FODMAP diet? (please check all that applies)
Monash App
Other Diet App
Handout
Google Search
Dietician
Medical Provider (Physician, Physician Assistant, or Nurse Practitioner)
Nurse
29.
The low FODMAP diet helped my Irritable Bowel Syndrome symptoms?
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
I have not tried the low FODMAP diet
30.
I did not try the low FODMAP diet because
It was too limited
I could not afford it
I prefer to use another treatment for my Irritable Bowel Syndrome
It is too hard to understand
Not Applicable
31.
Does anyone else in your family have to follow a special diet?
Yes
No
Current Progress,
0 of 31 answered